Medicare Advantage and Part D: What’s New for 2026? A Comprehensive Look at the Latest CMS Guidance Updates

As we approach 2026, the Centers for Medicare & Medicaid Services (CMS) has released critical updates to the Medicare Advantage (MA) and Part D Enrollment and Disenrollment guidance. These changes are set to take effect for enrollments beginning January 1, 2026, and they reflect CMS’s continued effort to improve transparency, protect beneficiaries’ rights, and streamline enrollment and disenrollment processes.

This blog outlines the most impactful regulatory guidance updates—combining policy clarifications and standardized communication improvements—so MA organizations, health plans, brokers, and stakeholders can prepare accordingly.

Key Regulatory and Policy Changes

1. Updates to the Default Enrollment Process Includes Significant Clarification.

The most significant updates are in this section of the guidance.  The updates to 40.1.5 – Default Enrollment Option for Medicaid Managed Care Plan Enrollees who are Newly Eligible for Medicare – Part C only provide clarity on the application and renewal process.  Applications and renewals for Default Enrollment are submitted via HPMS in the Default Enrollment Module. 

Additionally, CMS has clarified rules around default enrollment into D-SNPs for Medicaid Managed Care enrollees becoming newly eligible for Medicare:

“Default enrollment is an enrollment process that allows an MA Organization (MAO)... to enroll an enrollee of an affiliated Medicaid managed care plan into its Medicare Dual Eligible Special Needs Plan (D-SNP) when that enrollee becomes eligible for Medicare (i.e., has both Medicare Part A and Part B for the first time) - unless the enrollee chooses otherwise.”

To qualify for default enrollment:

• The MAO must have an affiliated Medicaid managed care plan.

• Must receive approval from both CMS and the state via a SMAC.  Approval for use of default enrollment process from CMS is for up to five years.

• Must meet minimum quality ratings and data sharing protocols.

• Plans should not attempt to dissuade members from opting out. 

• The Plan is eligible to enroll new members.

CMS also emphasized the importance of:

• State Medicaid eligibility redeterminations.

• Timely noticing (at least 60 days before Medicare eligibility).

• And opt-out options clearly communicated in default enrollment letters (Exhibit 39).

• A contract consolidation or PBP crosswalk to a new PBP will require a new default submission request.

• To submit a default renewal application prior to the expiration of the previously approved period.  If a plan doesn’t submit the renewal application in that timeframe a new default enrollment application will be required. 

• How redetermination timeframes impact default enrollment opportunities as redetermination must be completed far enough in advance to allow the at least 60-day advance notice.

CMS also created a new letter to default enrollees (Exhibit 39) which includes critical information such as:

·       Whether the prospective enrollee’s primary care physician is in the D-SNP network.

·       The process to access services under the plan.

·       How the enrollee can opt out to enroll in Original Medicare or another MA plan.

·       Information on how to contact the plan to get information on differences in premium or cost shares or benefits between existing Medicaid plan and new D-SNP.

2. Passive Enrollment by CMS and Network and Benefit Comparability (Section 40.1.6)

Passive enrollment is a process where CMS automatically enrolls an individual into another plan. The individual receives a notice of this change and has the opportunity to accept or decline the enrollment. If the individual takes no action, the individual has made a choice to accept the enrollment.

In updates to criteria on the ability to receive passive enrollment for D-SNP continue access integrated care, CMS now requires D-SNPs to demonstrate:

• Substantially similar provider and facility networks using National Provider Identifiers (NPIs) to assess overlap in provider and facility specialty types for highest utilization for the dual eligibles,

• Operational capacity to handle new members including review of current vs future enrollment, Part C and Part D performance metrics, recent Medicare program audit and other enforcement activity,

• Substantially similar Medicare and Medicaid Covered Services:  CMS will evaluate PBPs and will consult with State Medicaid to verify that Medicaid benefits align with the new enrollments.

CMS clarified that supplemental benefits are not considered in benefit comparability assessments.

3. Expanded Medigap Notification Language (Exhibits)

Medigap rights have been a recurring area of member confusion. To improve member understanding during disenrollment, CMS added additional standardized Medigap notification language across multiple model notices. These updates apply when members switch from MA to Original Medicare. 

Enhanced Medigap Language Now Included in:

Exhibits 9, 9a, 11, 12, 21, 21a, 24, 32, 33, 35 and 36

There are 2 versions of the updated language.  All include:

Under “What are my Medigap rights?” or “Information about Medigap rights”“If you will be changing to Original Medicare, you may have a temporary right to buy a Medigap policy, also known as Medicare supplemental insurance, even if you have health problems. These are sometimes called “Guaranteed Issue (GI)” rights. For more information on Medigap, check out https://www.medicare.gov/health-drug-plans/medigap.

Federal law requires the protections described above be provided in certain situations when you are changing to Original Medicare. Your State may have laws that provide more Medigap protections. If you have questions about Medigap or Medigap rights in your State, you should contact your State Health Insurance Assistance Program <insert name of SHIP> at <SHIP phone number>. You can also call 1-800-MEDICARE (1-800-633-4227) anytime, 24 hours a day, 7 days a week for more information. TTY users should call 1-877-486-2048.”

Exhibit 12, 32 and 35 also include:

“You can also call us if you need proof of your Medigap rights, as applicable.”

4. Residence Verification and Incomplete Enrollments (Section 50 and Exhibit 34)

The guidance now includes more inclusive criteria for determining permanent residence:

“If an individual wants to join a plan but has no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where they receive mail (e.g. social security checks) may be considered their permanent residence address.”

This is especially relevant for individuals experiencing housing instability and is reflected in Exhibit 34.

5. Updated Definitions for Special Needs Plans (SNPs)

CMS updated five definitions related to Special Needs Plans to improve clarity and alignment across SNP categories.  CMS also included the new definitions in guidance where appropriate for I-SNPs.  New definitions include:

• “Facility-based Institutional Special Needs Plan (FI-SNP) Definition”

• “Hybrid Institutional Special Needs Plan (HI SNP) Definition”

• “Institutional Equivalent Special Needs Plans (IE-SNP) Definition”

• “Institutional Special Needs Plan (I-SNP) Definition (Which references IE_SNP, HI-SNP and FI-SNP)”

Additionally, an important change was formalized in this chapter from the 2024-0715 Final Rule published April 2024 regarding D-SNP enrollment coordination starting in 2027 for new enrollments, and fully enforced by 2030 for continuing to cover existing enrollments:

“FIDE SNP, HIDE SNP and AIP Beginning in plan year 2027, where an MAO offers a D-SNP and its parent organization (or any entity that shares a parent organization with the MAO) also contracts with a state as a Medicaid MCO that enrolls full-benefit dual eligible individuals in the same service area, the D-SNP must limit new enrollment to individuals enrolled in (or in the process of enrolling in) the D-SNP’s affiliated Medicaid MCO. This would apply when any part of the D-SNP service area(s) overlaps with any part of the Medicaid MCO service area, even if the two service areas do not perfectly align. Beginning in 2030, such D-SNPs must only enroll (or continue to cover) individuals enrolled in (or in the process of enrolling in) the affiliated Medicaid MCO, except that such D-SNPs may continue to implement deemed continued eligibility requirements as described in 42 CFR §422.52(d). More information about this exception can be found in Chapter 16-B.”

6. Updated Enrollment guidance also includes:

• Updated language for incomplete ICEP/IEP applications,

• Clarifications for involuntary disenrollment (§60.2) can include CMS involuntary disenrollments,

• And updates to grace period calculations (§60.3.1.2) to ensure it is at least two full months.

• Clarification that emails including an attached signed note of disenrollment are not permitted for voluntary disenrollments (§60.1)

7. Operational and Documentation Enhancements

• Separated out Medicare Advantage vs Prescription Drug Plan Model Notice Numbers throughout the document.

• Introductory statement indicates “Plans are expected to use the updated model enrollment form for enrollment requests received on or after January 1, 2026.”

• Exhibits 1: Removed all language on page 3 between “Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out” and “Select one if you want us to send you information in a language other than English.”

• Exhibit 1a: Expanded checkboxes for attestation of eligibility (e.g., recent move, D-SNP interest, or loss of SPAP assistance) and replaced quarterly dual/low income subsidy SEP

• Exhibit 1b (Model MSA Enrollment Form):  Removed all language on page 3 between “Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out” and “Please check one of the boxes below if you would prefer that we send you information in a language other than English or an accessible format:”

• Exhibit 1c (Model PFFS Enrollment Request): Removed all language on page 3/4 between “Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out” and “Please check one of the boxes below if you would prefer that we send you information in a language other than English or an accessible format:”

• Exhibit 1d (Model Simplified Enrollment Form ):   Removed all language on page 1/2 between “Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out” and “You are requesting enrollment into a Medicare Advantage Plan offered by <name of MA Organization>.”

• Exhibit 2 (Model Employer/Union Group Health Plan Enrollment Request):  Removed all language on page 2/3 between “Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out” and “Please check one of the boxes below if you would prefer that we send you information in a language other than English or an accessible format:”

• Exhibit 3 (Model Short Enrollment Request Form):  Removed all language on page 1/2 between “Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out” and “Please check one of the boxes below if you would prefer that we send you information in a language other than English or an accessible format:”

• Exhibit 10a:  Added an additional attestation option and removed quarterly dual/LIS SEP.

• Exhibit 19:  Added a word “Assistance” in “You should contact your State Health Insurance Assistance Program, <name of SHIP>, at <SHIP phone number(s)> to get more information”

• Exhibit 24:  Substantial added language.

• Exhibit 39: New model notice and Frequently Asked Questions confirming default enrollment, including required elements like PCP status, cost-sharing differences, and how to opt out.

• Exhibit 16,34, 35 and 36 : Update Social Security Hours

  
  

What Plans and Stakeholders Should Do Now

To stay compliant and beneficiary-focused, Health plans and related entities should:

• Update all affected model notices to include the new Medigap, disenrollment and other language is in place for enrollments processed for January 1, 2026 effective dates,

• Reassess default enrollment workflows, especially related to approval and renewal processes, new member notice requirements and process enhancements,

• Train enrollment staff on new guidance regarding eligibility, address verification, and default enrollment processes,

• Amend all Enrollment Form Versions.  Per introductory statement, “Plans are expected to use the updated model enrollment form for enrollment requests received on or after January 1, 2026.”

• Ensure all documentation and workflow processes are updated with these changes.

The 2026 guidance updates reflect CMS’s efforts to increase transparency, accuracy, and beneficiary protections in Medicare Advantage and Part D. By emphasizing consistent communication, clear Medigap rights, and careful enrollment oversight, these changes aim to create a more informed, equitable experience for all beneficiaries.

As the Annual Election Period approaches, now is the time to align your organization with these changes. Review your notices, refine your processes, and ensure that your teams are ready to support members with confidence and clarity while remaining complaint with all new guidance.

If you need help navigating the 2026 CMS guidance updates, Rebellis Group is here to ensure you’re ready.

We can help you:

• Stay compliant

• Validate network and benefit comparability for D-SNP and passive enrollment.

• Update notices and forms with new Medigap and disenrollment language.

• Modernize enrollment workflows and address verification processes.

• Provide interim staffing support

• Prepare for 2027–2030 D-SNP/Medicaid MCO coordination requirements.

• Train your teams so they’re confident, accurate, and member-focused.

From compliance to member communication — if you need support, we’re here.

Contact Us Today